Nokea
A nurse is caring for a client who is 6 weeks of gestation and reports nausea and vomiting. Which of the following Recommendations should the nurse make?
- A. Avoid Eating snacks before bedtime
- B. Eat high-fat snack before getting out of bed
- C. Drink additional liquids with each meal
- D. Consume food served at cool temperatures
Correct Answer: D
Rationale: The correct answer is D: Consume food served at cool temperatures. This recommendation is based on the fact that pregnant women experiencing nausea and vomiting (commonly known as morning sickness) may find relief by consuming cold or cool foods, as they are less likely to trigger nausea compared to hot or warm foods. Cold foods also tend to have less of a strong smell, which can help reduce nausea. Avoiding snacks before bedtime (choice A) may not necessarily alleviate nausea in the morning. Eating high-fat snacks before getting out of bed (choice B) may worsen nausea. Drinking additional liquids with each meal (choice C) may not address the underlying cause of nausea and could potentially make it worse.
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A nurse is assessing a client who is in preterm labor and has a new prescription or terbutaline 0.25 mg subcutaneous. For which of the following findings should the nurse Withhold the medication and Report to the provider?
- A. Fasting blood glucose 75 mg / DL
- B. Blood pressure 88/58 mmhg
- C. Urinary output 40 ml /hr
- D. FHR 120/min
Correct Answer: B
Rationale: The correct answer is B: Blood pressure 88/58 mmHg. Terbutaline is a tocolytic medication used to stop preterm contractions. A low blood pressure reading of 88/58 mmHg may indicate hypotension, a potential side effect of terbutaline. Hypotension can lead to decreased placental perfusion, putting the fetus at risk. The nurse should withhold the medication and report this finding to the provider for further assessment and intervention.
A: Fasting blood glucose of 75 mg/dL is within normal range and does not require withholding the medication.
C: Urinary output of 40 ml/hr is adequate and does not indicate a need to withhold the medication.
D: Fetal heart rate of 120/min is within the normal range for a fetus and does not require withholding the medication.
A nurse is using Niagele9s rule to calculate the expected delivery date of a client who reports the first day of the last menstrual cycle was July 28th. Which of the following dates should the nurse document as a client expected delivery date? 07/28
- A. April 21st
- B. April 4th
- C. May 5th
- D. May 21st
Correct Answer: C
Rationale: The correct answer is C: May 5th. To calculate the expected delivery date using Naegele's rule, add 7 days to the first day of the last menstrual period (July 28th), then subtract 3 months, and add 1 year. July 28th + 7 days = August 4th. Subtract 3 months = May 4th. Add 1 year = May 5th. Choice A is incorrect as it is too early. Choice B is incorrect as it is also too early. Choice D is incorrect as it is too late.
A nurse is reviewing the laboratory results of a newborn. Which of the following findings should the nurse report to the provider?
- A. Blood glucose 58 mg / DL
- B. Hematocrit 48%
- C. Platelets 100,000/ mm 3
- D. Hemoglobin 16 G / DL
Correct Answer: C
Rationale: The correct answer is C: Platelets 100,000/mm3. This finding is abnormal in a newborn and could indicate a potential bleeding disorder or thrombocytopenia, which requires immediate attention from the provider to assess and manage appropriately. Choice A (Blood glucose 58 mg/dL) is within normal range for a newborn. Choice B (Hematocrit 48%) and D (Hemoglobin 16 g/dL) are also within normal limits for a newborn and do not require immediate reporting.
A nurse is caring for a client who has gestational diabetes mellitus. Which of the following clinical findings should indicate to the nurse the client has hyperglycemia?
- A. Double vision
- B. Increased urination
- C. Sweating
- D. Dizziness
Correct Answer: B
Rationale: The correct answer is B: Increased urination. Hyperglycemia in gestational diabetes mellitus leads to elevated blood glucose levels, causing the kidneys to work harder to filter and remove excess sugar from the blood. This results in increased urination (polyuria) as the body tries to eliminate the excess glucose through urine. Double vision (A) is more indicative of neurological issues, sweating (C) can be due to various reasons such as anxiety or hormonal changes, and dizziness (D) may be related to blood pressure changes or inner ear problems. Therefore, increased urination is the most specific clinical finding associated with hyperglycemia in gestational diabetes mellitus.
A nurse is planning care for a newborn who is scheduled to start phototherapy using a lap. Which of the following actions should the nurse include?
- A. Apply a thin layer lotion to the newborn skin every 8 hours
- B. Trust in you born in a thin layer clothing during the therapy
- C. Ensure the newborn's eyes are closed beneath the shield
- D. Give the newborn 1 oz of glucose water every 4 hours
Correct Answer: C
Rationale: The correct answer is C: Ensure the newborn's eyes are closed beneath the shield. This is crucial during phototherapy to protect the newborn's eyes from potential damage caused by the bright lights. Newborns undergoing phototherapy should have their eyes shielded with protective eye coverings to prevent eye damage. Choice A is incorrect as lotion can intensify the effects of phototherapy. Choice B is incorrect as the newborn should be undressed to maximize skin exposure. Choice D is incorrect as glucose water is not indicated for phototherapy and may interfere with treatment.